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Achilles Tendon Lesions – Part 1: Tendinopathies Lesões Do Aquiles – Parte 1: Tendinopatias

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Achilles Tendon Lesions – Part 1: Tendinopathies Lesões Do Aquiles – Parte 1: Tendinopatias THIEME Update Article 657 Achilles Tendon Lesions – Part 1: Tendinopathies Lesões do Aquiles – Parte 1: Tendinopatias Nacime Salomão Barbachan Mansur1 Lucas Furtado Fonseca1 Fábio Teruo Matsunaga1 Daniel Soares Baumfeld2 Caio Augusto de Souza Nery1 Marcel Jun Sugawara Tamaoki1 1 Department of Orthopedics and Traumatology, Escola Paulista de Address for correspondence Nacime Salomão Barbachan Mansur, Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil PhD, Departamento de Ortopedia e Traumatologia, Escola Paulista de 2 Department of Orthopedics and Traumatology, Universidade Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros, Federal de Minas Gerais, Belo Horizonte, MG, Brazil 715, 1° andar, Vila Clementino, São Paulo, SP, Brazil (e-mail: [email protected]). Rev Bras Ortop 2020;55(6):657–664. Abstract Calcaneal tendon injuries are extremely common in the general population and in orthopedics routine care. Its increasing incidence, which is motivated by an aging population, improved access to the health care system, increased prescription of Keywords continuous-use medication, erratic participation in sports and other factors, has had a ► tendinopathy direct impact on society. Consolidated treatment options for tendinopathies lack ► calcaneus tendon/ quality scientific support for many modalities. New therapies have emerged to enhance surgery nonsurgical approach outcomes and to reduce the number of patients requiring ► insertional surgery. Although these operative procedures provide good pain relief and functional ► non-insertional outcomes, they are costly and may lead to complications. Resumo As afecções que acometem o tendão calcâneo são extremamente comuns na população geral e no cotidiano da atenção ortopédica. Sua crescente incidência, motivada pelo envelhecimento da população, pela melhora no acesso à saúde, pelo aumento na utilização de drogas de uso contínuo, pela errática participação esportiva e outros fatores, tem causado impacto direto na sociedade. As tendinopatias, ainda que Palavras-chave hoje respaldadas por tratamentos consolidados, carecem de suporte científico de ► tendinopatia qualidade para muitas das suas recomendações. Novas terapêuticas têm surgido com o ► tendão do calcâneo/ objetivo de potencializar o resultado da abordagem não-operatória e diminuir a cirurgia quantidade de pacientes que necessitam de uma cirurgia. Esses procedimentos ► insercional operatórios apresentam uma boa resposta álgica e funcional dos pacientes, no entanto ► não insercional nãosãolivresdecomplicaçõesedosaltoscustosqueoscercam. fi Introduction this structure rotates about 180 degrees, and the soleus bers form the medial portion and the lateral gastrocnemius fibers Achilles Tendinopathies form the distal portion of the tendon. This rotation provides The calcaneal tendon is the strongest and thickest tendon in greater tendinous strength and resistance by decreasing the the human body.1,2 It originates from the confluence of the friction between the fibers and their distortions. However, it soleus and gastrocnemius muscles (which has two bellies); the may compromise local vascularization.4 whole unit is referred to as triceps surae.3 These bellies form The area two to six centimeters proximal to the insertion the tendon about six centimeters (proximal) from its attach- is designated the non-insertional region. It has low vascular- ment into the calcaneal bone posterior tuberosity. In its path, ization due to its distance from the myotendinous and bony received DOI https://doi.org/ Copyright © 2020 by Sociedade Brasileira September 10, 2019 10.1055/s-0040-1702953. de Ortopedia e Traumatologia. Published accepted ISSN 0102-3616. by Thieme Revinter Publicações Ltda, Rio November 29, 2019 de Janeiro, Brazil 658 Achilles Tendon Lesions – Part 1: Tendinopathies Mansur et al. portions, which account for additional nutritional support. ative capacity explain the bimodal incidence of these diseases. These anatomical features predispose this region to degen- Young patients practicing high-demand physical activities and erative diseases and ruptures. Distally, the tendon has a middle-aged people with compromised healing potential are – particular anatomy, which also favors tendinopathies. The the populations most affected by this condition.4,9 11 insertional region refers to the two distal centimeters of the Pes cavus, flatfoot, ankle instability, gender, and overweight tendon until its attachment in the os calci. In this location, the are also related to intratendinous degeneration. Some authors Achilles tendon has an adjoinig anterior (retrocalcaneal) consider them risk factors for the disease, despite the mechan- bursa and an also adjoinig posterior (pre-Achillean or sub- ical overload inherent to them. In the non-insertional form of cutaneous) bursa. Its insertion into the tuberosity is special- the disease, the presence of a plantaris tendon in close contact ized, spread out as a fan, with fibers extending to the lateral, with the Achilles tendon, with a different kinematics, was medial, and distal planes.1 indicated as a disease inducer. Genetic inheritance, in addition This enthesis is extremely particular, and some authors to the clear relationship with some collagen metabolism consider it a particular organ. It is formed by the osteoten- diseases, plays a relevant part in tendinopathy as the condition dinous junction, covered by a sesamoid fibrocartilage adja- is identified in relatives and in studied populations with cent to the tendon, the dorsal periosteum of the tuberosity, combined polymorphisms and genotypes.12,13 and the apex of the Kager fat pad. The bursas are distal in this In the last decades, comorbidities, including rheumatoid topography.2,5 The calcaneal tendon microanatomy respects arthritis, reactive arthritis, spondyloarthropathies, lupus, the organization of other human tendons. Up to 95% of its deposition disorders (gout and pseudogout), diabetes melli- cellular component is formed by tenocytes and tenoblasts. tus, amyloidosis, hypercholesterolemia, nephropathies, Mar- These cells have different sizes and shapes and dispose fan syndrome, Ehlers-Danlos disease, hemochromatosis and themselves in long, parallel chains. Ninety percent of the osteogenesis imperfecta, have been related to tendinopa- extracellular element is composed of collagen tissue, pre- thies. Quinolone, statins, steroids (including anabolic ste- dominantly type I (95%), organized in parallel bands bound roids) and non-hormonal antiinflammatory drugs have also by small proteoglycan molecules. About 2% of this element is been reported as tendinopathy promoters due to the inhibi- formed by elastin, which accounts for the tendon deforma- tion of natural collagen synthesis. However, a recent system- tion capacity of up to 200% before failure. Aging and the atic review pointed only to alcohol abuse and the use of inability to provide optimal tissue healing modify this con- ciprofloxacin as systemic risk factors with strong evidence figuration, promoting the accumulation of mucin, fibrin, and for the development of Achilles tendinopathies.14,15 types III and VII collagen.2,6 Calcaneal tendinopathy is classified according to its ana- Non-insertional Achilles Tendinopathy tomical site as insertional and non-insertional. Achilles insertional tendinopathy (AIT) occurs when the disease Epidemiology occurs from the insertion up to two centimeters proximally. Achilles non insertional tendinopathy (ANIT) have an inci- It is usually associated with traction enthesophytes (upper dence of about 1.85 per 1,000 inhabitants, accounting for 6 to spurs), Haglund deformity (pump bump) and pre- and retro- 17% of injuries in runners.4,16 The prevalence of this condi- Achillean bursopathies. The differentiation between the two tion is estimated at 0.2% in sedentary individuals and 9% in injury sites is not merely topographic, and this is consensual athletes, with an incrasing aspect in recent decades. The in the literature. The epidemiology of the two conditions is treatment costs average around € 2,500 per patient for different, and there are disparate etiological theories, al- conservative treatment, with a 6-fold increase when surgical though with some similarities. Although they can coexist resolution is considered.17,18 both asymptomatically and symptomatically (mixed calca- neal tendinopathy), they are considered distinct disorders Clinical Presentation regarding clinical presentation and treatment.7,8 Patients commonly seek care complaining of tendon-related body pain (2–6 cm proximal to the insertion) after activities; Pathophysiology over time, pain may occur during sports or work. Regional Calcaneal tendinopathy is characterized by intratendinous stiffness is not uncommon, and it may even precede pain onset. degenerations secondary to low-grade inflammatory Swelling is mainly noted in individuals with more chronic responses and poor biological healing. There are multiple conditions.4,19 hypotheses for the etiology of this disease, including overuse, Physical examination must include alignment assessment muscle imbalance, misalignment and aging-related blood for deformities (pes cavus, flat foot, congenital diseases). The supply and tensile strength decrease. Currently, the etiology diagnosis is clinical and established by a painful tendon body is believed to be multifactorial, with mechanical, vascular, palpation; tendon may also be hypertrophic. Medial tendon neural, and genetic factors playing different roles in the pain is highly suggestive
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